Basic Suturing
Objectives
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Describe the principles of wound healing
Identify the various types and sizes of suture material.
Choose the proper instruments for suturing.
Identify the different injectable anesthetic agents and correct
dosages.
Demonstrate different types of closure techniques: simple
interrupted, continuous, subcuticular, vertical and horizontal
mattress, dermal
Demonstrate two-handed, one-handed, instrument ties
Recommend appropriate wound care and follow-up.
Critical Wound Healing Period
Tissue
Skin
5-7 days
Mucosa
5-7 days
Subcutaneous
7-14 days
Peritoneum
7-14 days
Fascia
14-28 days
0
5 7
14
21
Tissue Healing Time/Days
28
Model of Wound Healing
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(1) Hemostasis: within minutes post-injury, platelets aggregate at the
injury site to form a fibrin clot.
(2) Inflammatory: bacteria and debris are phagocytosed and removed,
and factors are released that cause the migration and division of cells
involved in the proliferative phase.
(3) Proliferative: angiogenesis, collagen deposition, granulation
tissue formation, epithelialization, and wound contraction
(4) Remodeling: collagen is remodeled and realigned along tension
lines and cells that are no longer needed are removed by apoptosis.
Types of Sutures
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Absorbable or non-absorbable (natural or synthetic)
 Monofilament or multifilament (braided)
 Dyed or undyed
 Sizes 3 to 12-0 (numbers alone indicate progressively
larger sutures, whereas numbers followed by 0 indicate
progressively smaller)
 New antibacterial sutures
Absorbable
Non-absorbable
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Not biodegradable
and permanent
– Nylon
– Prolene
– Stainless steel
– Silk (natural, can
break down over
years)
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Degraded via
inflammatory response
– Vicryl
– Monocryl
– Chromic
– Cat gut (natural)
Natural Suture
Synthetic
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Biological
 Cause inflammatory
reaction
– Catgut (connective
from cow or sheep)
– Silk (from silkworm
fibers)
– Chromic catgut
Synthetic polymers
 Do not cause
inflammatory response
– Nylon
– Vicryl
– Monocryl
– Prolene
Monofilament
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Multifilament (braided)
Single strand of suture
material
Minimal tissue trauma
Smooth tying but more
knots needed
Harder to handle due to
memory
Examples: nylon, monocryl,
prolene,
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Fibers are braided or twisted
together
 More tissue resistance
 Easier to handle
 Fewer knots needed
 Examples: vicryl, silk,
chromic
Suture Selection
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Do not use dyed sutures on the skin
Use monofilament on the skin as multifilament
harbor BACTERIA
Non-absorbable cause less scarring but must be
removed
Plus sutures (staph, monocryl for E. coli,
Klebsiella)
Location and layer, patient factors, strength,
healing, site and availability
Suture Selection
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Absorbable for GI, urinary or biliary
 Non-absorbable or extended for up to 6 mos
for skin, tendons, fascia
 Cosmetics = monofilament or subcuticular
 Ligatures usually absorbable
Surgical Needles
Wide variety with different company’s
naming systems
 2 basic configurations for curved needles
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– Cutting: cutting edge can cut through tough
tissue, such as skin
– Tapered: no cutting edge. For softer tissue
inside the body
Surgical Needles
Surgical Instruments
Anesthetic Solutions
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Lidocaine (Xylocaine®)
– Most commonly used
– Rapid onset
– Strength: 0.5%, 1.0%, &
2.0%
– Maximum dose:
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5 mg / kg, or
300 mg
– 1.0% lidocaine = 1 g
lidocaine / 100 cc =
1,000mg/100cc
– 300 mg = 0.03 liter = 30
ml
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Lidocaine (Xylocaine®)
with epinephrine
– Vasoconstriction
– Decreased bleeding
– Prolongs duration
– Strength: 0.5% & 1.0%
– Maximum individual
dose:
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7mg/kg, or
500mg
Anesthetic Solutions
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CAUTIONS: due to its vasoconstriction
properties never use Lidocaine with epinephrine
on:
– Eyes, Ears, Nose
– Fingers, Toes
– Penis, Scrotum
Anesthetic Solutions
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BUPIVACAINE (MARCAINE):
– Slow onset
– Long duration
– Strength: 0.25%
– DOSE: maximum individual dose 3mg/kg
Injection Techniques
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25, 27, or 30-gauge
needle
 6 or 10 cc syringe
 Check for allergies
 Insert the needle at the
inner wound edge
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Aspirate
 Inject agent into tissue
SLOWLY
 Wait…
 After anesthesia has
taken effect, suturing
may begin
Wound Evaluation
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Time of incident
 Size of wound
 Depth of wound
 Tendon / nerve involvement
 Bleeding at site
When to Refer
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Deep wounds of hands or feet, or unknown depth
of penetration
Full thickness lacerations of eyelids, lips or ears
Injuries involving nerves, larger arteries, bones,
joints or tendons
Crush injuries
Markedly contaminated wounds requiring
drainage
Concern about cosmesis
Contraindications to Suturing
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Redness
Edema of the wound margins
Infection
Fever
Puncture wounds
Animal bites
Tendon, nerve, or vessel involvement
Wound more than 12 hours old (body) and 24 hrs
(face)
Closure Types
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Primary closure (primary intention)
– Wound edges are brought together so that they are adjacent to each
other (re-approximated)
– Examples: well-repaired lacerations, well reduced bone fractures,
healing after flap surgery
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Secondary closure (secondary intention)
– Wound is left open and closes naturally (granulation)
– Examples: gingivectomy, gingivoplasty,tooth extraction sockets,
poorly reduced fractures
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Tertiary closure (delayed primary closure)
– Wound is left open for a number of days and then closed if it is
found to be clean
– Examples: healing of wounds by use of tissue grafts.
Wound Preparation
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Most important step for reducing the risk of wound
infection.
Remove all contaminants and devitalized tissue before
wound closure.
– IRRIGATE w/ NS or TAP WATER (AVOID H2O2,
POVIDONE-IODINE)
– CUT OUT DEAD, FRAGMENTED TISSUE
If not, the risk of infection and of a cosmetically poor scar
are greatly increased
Personal Precautions
Principles And Techniques
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Minimize trauma in skin
handling
Gentle apposition with slight
eversion of wound edges
– Visualization
Make yourself comfortable
– Adjust the chair and the
light
Change the laceration
– Debride crushed tissue
Simple Interrupted Suturing
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Apply the needle to the needle driver
– Clasp needle 1/2 to 2/3 back from tip
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Rule of halves:
– Matches wound edges better; avoids dog ears
– Vary from rule when too much tension across
wound
Simple Interrupted Suturing
Rule of halves
Simple Interrupted Suturing
Rule of halves
Suturing
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The needle enters the
skin with a 1/4-inch
bite from the wound
edge at 90 degrees
– Visualize Erlenmeyer
flask
– Evert wound edges
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Because scars contract
over time
Suturing
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Release the needle from the needle driver, reach into the
wound and grasp the needle with the needle driver. Pull it
free to give enough suture material to enter the opposite
side of the wound.
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Use the forceps and lightly grasp the skin edge and arc the
needle through the opposite edge inside the wound edge
taking equal bites.
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Rotate your wrist to follow the arc of the needle.
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Principle: minimize trauma to the skin, and don’t bend the
needle. Follow the path of least resistance.
Suturing
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Release the needle and grasp the portion of the
needle protruding from the skin with the needle
driver. Pull the needle through the skin until you
have approximately 1 to 1/2-inch suture strand
protruding form the bites site.
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Release the needle from the needle driver and
wrap the suture around the needle driver two
times.
Simple Interrupted Suturing
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Grasp the end of the suture material with the needle driver
and pull the two lines across the wound site in opposite
direction (this is one throw).
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Do not position the knot directly over the wound edge.
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Repeat 3-4 throws to ensuring knot security. On each
throw reverse the order of wrap.
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Cut the ends of the suture 1/4-inch from the knot.
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The remaining sutures are inserted in the same manner
Simple, Interrupted
http://www.youtube.com/watch?v=PFQ5-tquFqY
The trick to an instrument tie
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Always place the suture holder parallel to the
wound’s direction.
 Hold the longer side of the suture (with the
needle) and wrap OVER the suture holder.
 With each tie, move your suture-holding hand to
the OTHER side.
 By always wrapping OVER and moving the hand
to the OTHER side = square knots!!
Two Handed Tie
Two Handed Tie
Suturing - finishing
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After sutures placed, clean the site with
normal saline.
 Apply a small amount of Bacitracin or
white petroleum and cover with a sterile
non-adherent compression dressing (Tefla).
Patient instructions and follow up care
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Wound care
– After the first 24-48 hours, patients should gently wash
the wound with soap and water, dry it carefully, apply
topical antibiotic ointment, and replace the
dressing/bandages.
– Facial wounds generally only need topical antibiotic
ointment without bandaging.
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Suture Removal
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Average time frame is 7 – 10 days
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FACE: 3 – 5 d
NECK: 5 – 7 d
SCALP: 7 – 12 days
UPPER EXTREMITY, TRUNK: 10 – 14 days
LOWER EXTREMITY: 14 – 28 days
SOLES, PALMS, BACK OR OVER JOINTS: 10 days
Any suture with pus or signs of infections should be
removed immediately.
Suture Removal
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Clean with hydrogen peroxide to remove any
crusting or dried blood
 Using the tweezers, grasp the knot and snip the
suture below the knot, close to the skin
 Pull the suture line through the tissue- in the
direction that keeps the wound closed - and place
on a 4x4. Count them.
 Most wounds have < 15% of final wound
strength after 2 wks, so steri-strips should be
applied afterwards.
References
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http://depts.washington.edu/uwemig/media_files/EMIG%20Suture%20Handout.pdf
Thomsen, T. Basic Laceration Repair. The New England Journal of Medicine. Oct.
355: 17.
Edgerton, M. The Art of Surgical Technique. Baltimore, Williams & Wilkins, 1988.
www.uptodateonline.com; 2009, topic lacerations, etc.
http://dermnetnz.org/procedures/pdf/suturing-dermnetnz.pdf
http://www.mnpa.us/handouts/Session%2005%20%20%20%20Basic%20Suturing%20%202010%20MNPA.pdf
http://www.practicalplasticsurgery.org/docs/Practical_01.pdf
http://health.usf.edu/NR/rdonlyres/ABB54A41-80A1-4E2B-8AE87EB5D06CE8DF/0/wound_healing_manual.pdf
Jackson, E. Wound Care – Suture, Laceration, Dressing: Essentials for Family
Physicians. AAFP Scientific Assembly. 2010.
http://www.aafp.org/online/etc/medialib/aafp_org/documents/cme/courses/conf/asse
mbly/2010handouts/071.Par.0001.File.tmp/071-072.pdf